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+ ^. United Way Agency r~, <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE REVISION NO. <br />❑ This is a. 3 Year Fixed Rate Policy <br />—ATIONALINSURANCE COMPANY <br />t4 <br />.npany Codc No. 29312 ❑New ❑ RrAion Policy No. 390000311111021 <br />jl <br />® Renewal: ❑ Reissue: ❑ Rewrite of Prior Policy No. 39000031WMI <br />Paget <br />Issue DAte 12-1 W2 <br />Awl. No. t9Tt97 <br />Pol. Term 1 Ym <br />Pay Term I Yr. I St. CA <br />I Co. <br />I Town <br />SG <br />yi, Adj. <br />Adjustment Date: <br />AUDITED <br />THIS INFORMATION PACE, WITH POLICY PROVISIONS AND ENDORSEMENTS, IF ANY. <br />Anniv. Rate Date: <br />COMPLETES THIS POLICY. <br />I <br />NAMED INSURED AND MAILING ADDRESS <br />PRODUCER m BRANCH CODE 010 <br />I TUTHWESr MINORITY PCONOMIC <br />AARIS, LLC <br />vEIOPMENT ASSOCIATION (USA) <br />37 GROVE STREET <br />-1, WEST 2ND STREET <br />SAt1 FRIW CISCO CA 94102 <br />3ANTA ANA CA NM <br />Insured is: ❑ Individual ❑ Pannership ❑ <br />Corporation, of Other. NON-PROFIT <br />O ther workplaces not shown about: <br />See Location Schedule <br />Identification number(s): <br />See Schedule <br />2. The policy period is from 10.27-2DO2 to <br />10-27.2003 at 12'.M A.M. Standard Time at the lnsured's mailing address. <br />iiach Old lnstaliment $ I Increase $ I Decrease E I Each New Installment S <br />A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation law of the states fated here: <br />CA <br />B. Employers Liability Insurance: Part Two of the policyapplies to the work in each State listed In Item 3.A. <br />The Limits of our Liability under Part Two are: Bodily Injury by Accident 1,000,000 each Accident <br />Bodily injury by 1)aeasc 1,000,000 policy limit <br />Bodily injury by DLcease 10M.000 each employee <br />Other Stater Insvmnce: All %tales eacept North Dakota, Ohio, Washington, West Virginia, Wyoming and states designated in ttem 3A of the <br />Information Page. <br />D. This policy includes these endorsements and schedules: <br />Sce Schedule of Forms and Endorsements'!; <br />1 Cinr <br />a. The premiwn for this policy will be determined by our Manual of Rules, Clan ificalions, Rates and Rating Pings. All information required on following <br />Claesif cation Schedule iv subject to verification apd change by Wadi[. Sec Extension Schedule Attached. <br />4,607 TOTAL ESTIMATED ANNUAL POLICY PREMIUM If indicated, interim adjustments of <br />ADJUSTMENT PREMIUM DUE (Addl., or Rcturn Premium -A minus premium shall be made; <br />fi rc means Retum Premium ❑ Scmi-Annually <br />$ 1,M1 MINIMUM PREMIUM ❑ Quarterly <br />$ DEPOSIT PREMIUM ❑Monthly <br />